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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216804402
Report Date: 04/07/2026
Date Signed: 04/07/2026 01:34:25 PM

Document Has Been Signed on 04/07/2026 01:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRIDGE CAREHOME, THEFACILITY NUMBER:
216804402
ADMINISTRATOR/
DIRECTOR:		ELLAZAR, STEPHANIEFACILITY TYPE:
740
ADDRESS:181 LUCAS PARK DR.TELEPHONE:
(707) 853-9915
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY: 6CENSUS: 0DATE:
04/07/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Applicant, Stephanie Ellazar, and Staff Member, Gigi BorjaTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived announced to conduct a pre-licensing inspection visit and met with Applicant, Stephanie Ellazar, and Staff Member, Gigi Borja. Facility intends on providing care and assistance to older adults and will have a dementia program plan on file. Facility received an approved fire clearance dated 03/03/2026 that allows for a total capacity of 6 non-ambulatory clients. Facility submitted their emergency disaster plan and infection control plan which was last reviewed on 03/02/2026. Per conversation with Applicant, they have requested for a hospice waiver for 6 individuals.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Per facility sketch, facility consists of 5 resident bedrooms, 2 bathrooms, and common spaces. Facility garage was converted into office and storage spaces. Per Applicant, the office and storage spaces in the facility sketch are intended to be for staff members only, consisting of an main office area, laundry, and two live-in staff rooms. LPA requested for an updated facility sketch and fire clearance to be submitted to accurately reflect the home's layout. LPA received updated facility sketch during visit. Applicant contacted the Marin Fire Department who stated they could reassess the home today, 04/07/2026.

Facility was found to be clean and at comfortable temperature with all exits free from obstruction. Resident rooms were observed to have appropriate furnishings per Title 22 Regulations. Facility's fire extinguisher was located by the main entryway and was last inspected December 2025. Cleaning products and other toxins and chemicals were observed to be locked under one of the bathroom sinks. Kitchen knives and other sharps were observed to be in a locked kitchen cabinet. Facility was observed to have appropriate linens and paper products available for resident use. Applicant intends on storing resident medication, resident files, and staff files in the converted garage. Hot water temperatures for facility sinks were found to be out of compliance with Title 22 Regulations of 105F to 120F measuring at 145.2F, 138.2F, 149.3F, and

Continued on LIC809C
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BRIDGE CAREHOME, THE
FACILITY NUMBER: 216804402
VISIT DATE: 04/07/2026
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Continued from LIC809

149.1F. Facility was observed to have some nonperishable and perishable foods on hand and had sufficient items for eating. LPA observed 3 pots and 1 saute pan on-site. Facility to purchase additional nonperishable items to meet 7-day requirement and more cookware. Facility's smoke detectors and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid kit was sufficient. Facility to install landline telephone for resident use. Facility had required posters displayed. LPA observed un-installed ramp railings and other items being stored against the side of the house in the backyard. LPA did not observe any pathways obstructed. Component III was reviewed with Applicant and Staff Member.

Applicant to submit photos and/or documents of the following corrections:
  • Updated and approved fire clearance
  • 3 day water temperature log showing temperatures within Title 22 Regulations of 105F to 120F.
  • Removed items observed in the backyard against the house
  • Installed railings for outside ramps
  • Installed landline for resident use
  • Proof of nonperishable goods to meet 7 day requirement
  • Proof of enough cookware/pots/pans
  • Ensure that Live-In Staff personal items are removed from resident rooms

Photos to be submitted to the Department by end of business on Friday, 04/10/2026.

Pre-Licensing completed and Advisories Issued. Facility is ready to be Licensed as a Residential Facility for the Elderly (RCFE) once photos and documents have been received and reviewed. LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status.

Exit interview conducted. Copy of report discussed and provided to Applicant. Signature on form confirms receipt of documents.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Caitlynn Felias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2026
LIC809 (FAS) - (06/04)
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